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Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
https://doi.org/10.1186/s44167-024-00064-6 Journal of Activity, Sedentary
and Sleep Behaviors
*Correspondence:
Chelsea L. Kracht
Ckracht@kumc.edu
Full list of author information is available at the end of the article
Abstract
Background Physical activity, sedentary behavior, and sleep, collectively known as the 24-hour movement behaviors,
demonstrate individual and joint benets on physical and mental health. Examination of these behaviors has
expanded beyond guideline adherence to reviews of isotemporal substitution models (ISM) and compositional data
analysis (CoDA). This umbrella review sought to review existing systematic reviews to (1) characterize the breadth
and scope, (2) examine prevalence estimates for 24-hour movement guideline adherence, and (3) examine the
relationship between these behaviors with health outcomes based on various approaches.
Methods Eight databases and multiple supplementary strategies were used to identify systematic reviews, meta-
analyses and pooled analyses that included two or more of the three 24-hour movement behaviors and a multi-
behavior assessment approach. Overall review characteristics, movement behavior denitions, approaches, and
health outcomes assessed were extracted, and methodological quality was assessed using the AMSTAR2 tool. Review
characteristics (Aim 1), guideline prevalence estimates (Aim 2), and associations with health outcomes (Aim 3) were
examined.
Findings Thirty-two reviews (20 systematic reviews, 10 meta-analyses, and 2 pooled analyses) were included.
Reviews captured the entire lifespan, global regions, and several physical and mental health outcomes. Individual
and total guideline adherence waned from preschool to adolescence, but reviews reported similar prevalence
estimates and ranges (i.e., within 10%). Common approaches included ISM and CoDA, evaluating 24-hour movement
behavior’s interactive associations with health outcomes, guideline adherence, and prole-based analysis. Despite
heterogeneous approaches, reviews found consistent evidence for benecial associations between meeting all three
guidelines and high amount of physical activity on physical and mental health outcomes, but varied assessment of
sedentary behavior or sleep. Most reviews were rated as low or critically low quality.
Conclusions The breadth and scope of current reviews on 24-hour movement behaviors was wide and varied in this
umbrella review, including all ages and across the globe. Prevalence estimates among populations beyond children
need to be synthesized. Amongst the variety of denitions and approaches, reviews found benet from achieving
24-hour movement behavior adherence
and associations with health outcomes: an
umbrella review
Chelsea L.Kracht1*, SarahBurkart2, Claire I.Groves3, Guilherme MoraesBalbim4, Christopher D.Pedderer5, Carah
D.Porter7, Christine W.St. Laurent6, Emily K.Johnson3 and Denver M. Y.Brown7
Page 2 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
Introduction
Physical activity, sedentary behavior, and sleep, which
are collectively referred to as 24-hour movement behav-
iors, are critical for physical and mental health across the
lifespan [1–6]. ese behaviors are unique, due to their
mutually exclusive properties and reciprocal relation-
ships across the 24-hour day. eir mutually exclusive
properties refer to engaging in one behavior at a time,
whereas their reciprocal relationship is shown in engag-
ing in one behavior may inuence amounts of other
behaviors. An example of this reciprocal association is
engaging in more physical activity during the day may
result in additional overnight sleep [7]. Recognizing these
interrelated and distinct properties, multi-behavior guid-
ance for children’s physical activity, recreational (children
and adolescents) or sedentary (young children) screen-
time, and sleep, and subsequent guidelines were created
from a Canadian group in 2016 [8–10]. ese integrative
guidelines mirror individual behavior guidance but pro-
pose a focus on achieving healthy amounts of all three
behaviors across the course of a whole day. e early
years (ages 0–5 years), child, and adolescent guidelines
have since been adopted by multiple high-income coun-
tries [11, 12], low- and middle-income countries [13], and
most recently, adult and older adult public health guid-
ance has been established [14]. Since the creation of these
guidelines, frameworks to advance 24-hour movement
research have emerged, which has been accompanied by
the application of several analytic approaches to examine
associations with health beyond threshold-based guide-
line adherence [15]. e Viable Integrative Research in
Time-Use Epidemiology (VIRTUE) Framework proposes
a path forward to advance research in eld of time-use
epidemiology through adequately accounting for the
compositional nature of 24-hour movement behaviors
when investigating methods, association with outcomes,
optimal time balance and prevalence, correlates of time-
use, and eventual design of eective interventions [15].
As noted by others, a consensus on 24-hour-related ter-
minology does not exist; the 24-hour movement behav-
iors may also be referred to as the 24-hour activity cycle,
time-use behaviors, time-use activity behaviors, and
physical behaviors [16]. is heterogeneity in terms and
application may make gathering and comparing scientic
investigations dicult, hence impeding ability to quantify
the collective contribution of 24-hour movement behav-
iors to health outcomes and advance to eventual time-use
interventions [15].
Since the release of the initial 24-Hour Movement
Guidelines for Children and Youth, 24- hour movement
research has grown globally; two major events occur-
ring in 2020 may have contributed to the proliferation
of research in this area. First, the World Health Orga-
nization released integrative guidelines for both physi-
cal activity and sedentary behavior, which represent key
time-use components within a 24-hour day [17, 18].
However, this momentous step towards a multi-behavior
focus was overshadowed by a global pandemic occurring
in the same year. In early 2020, individuals began social
distancing amongst the SARS COVID-19 pandemic;
many were less active, spent additional time sitting, and
varying changes in sleep durations and timing due to
these macrosystem level changes [19]. ese changes
in 24-hour movement behaviors were linked to gaining
additional weight and impaired mental health, especially
in children, amongst multiple systematic reviews [19,
20]. ese reviews also indirectly captured the increase
in 24-hour movement behavior research. As shown by
two separate systematic reviews, publications on 24-hour
movement behaviors prior to 2020 (n = 51) [21] tripled
within the year 2020–2021 alone (n = 150) [19].
is multi-behavior approach has also prompted the
adoption of innovative analytic approaches to handle
their collinear properties, namely isotemporal substi-
tution modelling (ISM) and compositional data analy-
sis (CoDA). ISM is an analytic approach that allows for
hypothetical substitutions or reallocations of time across
dierent movement behaviors within a xed period (e.g.,
24-hour day) [22]. Initial systematic reviews of studies
using the ISM approach to 24-hour movement behaviors
display predicted benet from reallocating time, namely
sedentary time, to moderate-to-vigorous physical activ-
ity (MVPA) and sleep on multiple physical and mental
health outcomes [23, 24]. Another approach is CoDA,
which was adopted from other elds [25] and rst applied
to 24-hour movement behaviors to examine associations
with indicators of health in 2015 [26]. Application of
CoDA techniques is central to the VIRTUE Framework
[15]. CoDA involves transformation of behavioral data
via log ratios to consider that each movement behavior
represents a unique and relative (i.e., versus absolute)
component of a xed period [27]. e transformed data
can then be explored as total, combined, and individual
parts of the day in relation to health outcomes. Relation-
ships with health outcomes based on these approaches
may be slightly dierent than traditional approaches (i.e.,
linear regression with absolute behavioral values), as this
healthy amounts of all three behaviors. Longitudinal multi-behavior original research studies with rigorous assessment
of sleep and sedentary behavior may help improve future systematic reviews of these various approaches.
Keywords Screen-time, Sitting time, Sedentary behavior, Sleep, Physical activity, Adherence
Page 3 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
approach considers the multicollinear nature of 24-hour
time-use data, taking into account the inuence of each
behavior relative to time spent engaging in other behav-
iors [27, 28]. CoDA approach utilization has grown over
the past decade, leading to subsequent reviews further
exploring associations between 24-hour movement com-
positions and health outcomes [29], and creating a digi-
tal interface to estimate the exact reduction in health risk
based on previous CoDA studies [30].
As the interest in 24-hour movement behaviors rose, so
did reviews to synthesize the collective impact of these
behaviors on health outcomes. Early systematic reviews
assessed 24-hour movement behaviors by adherence to
the child and youth 24-hour movement guidelines (i.e.,
physical activity duration, recreational screen-time, and
sleep duration) and found the most benet from meet-
ing all three guidelines [31]. ough amongst the prolif-
eration of 24-hour movement guideline adherence and
CoDA, multiple reiterations of movement behaviors
and approaches have emerged. For example, others have
examined prole-based analysis (e.g., high physical activ-
ity, low sleep) on health outcomes [32], or conducted
pooled analyses of all three behaviors using device-based
measures [33].
A systematic search of existing systematic reviews is
a lucrative method to characterize current evidence on
24-hour movement behavior guideline adherence, and
relationships between these behaviors with health out-
comes. Synthesizing the breadth and scope of these
systematic reviews may help identify population and
knowledge gaps for future systematic reviews and origi-
nal research studies. Additionally, examining the various
approaches to understand 24-hour movement behaviors
in relation to health outcomes may provide detailed guid-
ance for future reporting recommendations. erefore,
the purpose of this systematic review was two-fold: Aim
1) to characterize the breadth, and scope of systematic
reviews and meta-analyses examining at least two of the
physical activity, sedentary behavior, and sleep concur-
rently; Aim 2) examine prevalence estimates for 24-hour
movement guideline adherence; Aim 3) to examine asso-
ciations with health outcomes by various approaches.
Together these eorts may help describe the current
landscape of 24-hour movement behavior research to
help harmonize investigations in the literature, identify
actionable targets for future research, and focus eorts to
promote appropriate amounts of all behaviors.
Methods
Search strategy
is umbrella review followed a scoping review meth-
odology, thus follows the recommended reporting
guidelines of the Preferred Reporting Items for System-
atic Reviews and Meta-Analyses for Scoping Reviews
(PRISMA-ScR, Supplemental Table 1) [34]. e proto-
col (i.e., research question, search strategy, inclusion/
exclusion, risk of bias, data extraction items) was regis-
tered prior to the conduct of the review (registration osf.
io/hwv2r). In collaboration with a librarian, the search
strategy was created based on past reviews focusing on
24-hour movement behaviors with the addition of terms
to obtain systematic reviews and meta-analyses [6]. ere
were no specic outcomes for this review (e.g., obesity),
so the primary search strategy focused on the behav-
iors. A key component of this search was including pos-
sible grey literature and global reach, given the focus on
24-hour movement behaviors beyond high-income coun-
tries. Accordingly, we searched eight databases in total
(See Supplemental Table 2). e rst 6 databases were
searched from inception to October 12th, 2023, includ-
ing: CINAHL, Medline (EBSCO), PsychINFO, SportDis-
cus, Scopus, and Web of Science. e seventh (Cochrane
Library) and eighth (Embase) were then searched from
inception to October 24th, 2023 and October 31st, 2023,
respectively. Supplemental search strategies included
backward citations (searching references of included
papers), forward citations (reviewing citations of the
included references), reviewing published articles from
a recently created 24-hour movement behavior specic
journal (Journal of Activity, Sleep, and Sedentary Behav-
ior) and international database of time-use epidemiol-
ogy (International Network of Time-Use Epidemiologists),
contacting experts in the eld, and inclusion of gray
literature.
Eligibility criteria
Detailed inclusion and exclusion criteria can be found
in Table 1. In brief, systematic reviews, meta-analyses,
or harmonized (pooled) data analyses were eligible if
they were published in the English language, in peer-
reviewed literature, or gray literature (e.g., dissertation).
e population included was humans without age con-
straints, and the exposure was at least 2 of the 3 possible
24-hour movement constructs (physical activity, seden-
tary behavior, or sleep) in their research question. ese
constructs were created based on recognized criteria for
each behavior (Table1) [15, 35–38]. As of current, there
is no consensus on terminology or reporting for 24-hour
movement behaviors though many consider all three
constructs a requirement for this research [15, 39]. Two
constructs were allowed to accommodate related 24-hour
movement terminologies (i.e., physical behaviors, which
includes only physical activity and sedentary behavior)
[16, 40] and current World Health Organization guid-
ance (only physical activity and sedentary behavior) [18]
as both align with 24-hour movement research, and
may have guided systematic review research questions.
e major topics explored in each aim were breadth
Page 4 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
and scope, prevalence estimates, and associations with
health outcomes, respectively. Health outcomes were
not required for Aim 1 or 2. e outcomes for Aim 3
included physical (e.g., obesity) or mental health (e.g.,
quality of life) outcomes.
Articles were excluded if they were in a language other
than English, a form other than systematic review (e.g.,
narrative review, commentary, book chapter, etc.), or
included animal studies within the review. e original
references for country-specic 24-hour movement guide-
lines were excluded if their systematic review process was
not documented in detail in the current article. However,
if they referenced another article with additional detail
on their systematic review process, the referenced article
was then retrieved for consideration. Beyond article type
and population, there were ve other main exclusion rea-
sons starting from study design, behaviors included, and
outcomes. ese main exclusion reasons were operation-
alized as reviews focused on (1) solely interventions to
change 24-hour movement behaviors (e.g., school-based
interventions to improve physical activity and limit sit-
ting) [41], (2) methods to assess 24-hour movement
behaviors (e.g., quality assessment of methods) [42], (3)
only one behavior assessed [43], (4) dierent investiga-
tion of movement behaviors as either part of a cluster of
modiable factors [44], correlates of movement behaviors
[45], or as the outcome (e.g., ambient air quality impact-
ing physical activity or sedentary behavior) [46], and (5)
investigating the association between movement behav-
iors with another health behavior (e.g., alcohol consump-
tion), amongst themselves [47], or other health marker
(e.g., energy compensation) [48] as an outcome.
Study selection
Abstract and full-text screening stages were performed
by eight independent reviewers (CLK, SB, CWSL, CDPf,
GMB, CG, CDPo, DMYB) in duplicate, and conicts
were resolved by a third reviewer. A pre-piloted proto-
col for both stages was created prior to study selection.
Reviewers reached > 80% agreement prior to completing
both stages. Covidence systematic review software (Veri-
tas Health Innovation, Melbourne, Australia) was used to
facilitate study ow for abstract and full text screening,
and subsequent data extraction.
Data extraction and critical appraisal
Data extracted was related to article information
(author, year of publication), review question, popula-
tion included, 24-hour movement behavior denitions,
approaches, health outcome denitions, prevalence
Table 1 Detailed inclusion and exclusion criteria for review
Component Inclusion Exclusion
Language English Non-English
Information
source
Peer-reviewed literature, grey literature: dissertations or theses, and conference proceedings and
abstracts
Sources of gray literature not
identied in the inclusion
criteria (e.g., book chapters)
Population Humans, no age constraints Animals
Exposure Includes 2 of the 3 24-hour movement behaviors (sleep, sedentary behavior, and physical activity)
within research question. Below are denitions of each behavior.
• Sleep: a spontaneous and reversible state of rest characterized by inhibition of nearly all voluntary
muscles and reduced interactions with surrounding environment.
o Metrics included: All possible time-based sleep metrics (time in bed, actual sleep time).
• Sedentary behavior/time: Time spent sitting or reclining posture (Metabolic equivalent of tasks
[METs] < 1.5). Time and context were considered.
o Metrics included: Sedentary or recreational screen-time (TV, Computer, portable devices, etc.), sed-
entary time as measured by accelerometry or actigraphy, and sitting time / stationary behavior.
• Physical Activity: Physical activity is activity > 1.5 METs. Time and context were considered.
o Metrics included: Light physical activity (PA), Moderate PA, Vigorous PA, Total PA, Moderate-to-
vigorous PA (MVPA)
o Time spent outdoors or activities that usually elicit physical activity benet (e.g., sports, yoga)
was also considered
• Only includes 1 of the 3 24-
hour movement behaviors
• Assesses requirements not
related to 24-hour move-
ment behaviors (e.g., Non-
wear time)
Outcomes • Aim 2: No health outcomes, but report prevalence estimates of 24-hour movement guideline
adherence
• Aim 3: Physical (e.g., obesity) or mental health (e.g., stress) outcomes
• Methodologies to assess 24-
hour movement behaviors
• Health Behavior (e.g., smok-
ing, diet)
Study Design • Systematic Review
• Meta-Analyses
• Commentary (i.e., no new
data is presented)
• Narrative Review
• Original Investigation
• Reviews of Qualitative
studies
• Case studies
Page 5 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
estimates of meeting public health guidelines for each
movement behavior, relationships between movement
behaviors (in total and individually) with health out-
comes, overall results, proposed future directions, and
information related to review quality and risk of bias.
is information was curated based on past reviews and
expert opinions, as experts (n = 10) were asked to provide
input on extraction items when surveyed for additional
reviews. Data was extracted in duplicate by independent
reviewers and disagreements were resolved by a third
reviewer.
e Measurement Tool to Assess Systematic Reviews
(AMSTAR) 2 was used as a critical appraisal tool for
the included systematic reviews and meta-analyses [49].
Pooled analyses were graded but no total score was
assigned. is tool assesses seven critical domains of the
review including (1) protocol registration, (2) appropri-
ateness of literature search, (3) exclusion reasons, (4) risk
of bias for the included studies, (5) meta-analysis meth-
ods (when applicable), (6) interpretation of risk of bias,
and (7) publication bias assessment. AMSTAR-2 scores
were categorized based on number of critical and non-
critical weaknesses, with categories ranging from “high "
(no critical or non-critical weaknesses), “moderate” (no
critical weaknesses, with one or more non-critical weak-
ness), “low” (one critical weakness and multiple non-crit-
ical weaknesses), or “critically low” (multiple critical and
non-critical weaknesses).
Synthesis of results
For Aim 1, a numerical analysis (central tendencies)
related to population included, and review conduct.
Countries included in systematic reviews were classi-
ed into regions based on updated World Health Orga-
nization region guidance [50]. Reviews were further
described by their AMSTAR 2 quality rating (critically
low, low, moderate, and high). For Aim 2, prevalence esti-
mates for meeting individual and total guidelines were
extracted and compared. A meta meta-analysis was not
conducted with prevalence estimates due to signicant
study overlap; rather, each review’s calculated estimates
are described as reported by authors. For Aim 3 reviews
that assessed the relationship between 24-hour move-
ment behaviors and health outcomes were included.
Within these reviews, a qualitative description of 24-hour
movement behavior terminology and approaches used,
associations between movement behaviors with health
outcomes, health outcome denitions, and review nd-
ings was conducted.
Results
e initial search yielded 1,841 references, of which 1,037
were removed as duplications (Figs.1). After the title and
abstract screening of 804 references, the remaining 104
full texts were considered for inclusion. Supplementary
methods identied an additional 1,535 references, namely
via citation searching, which resulted in 30 additional
full texts for consideration (133 full texts total). Reviews
could be excluded for multiple reasons, but based on
the rst reason many references were removed at the
full-text stage for being the wrong article type (n = 42) or
wrong investigation of behaviors (e.g., behaviors as out-
comes, n = 25, Supplemental Table 3). e nal sample
included 32 reviews comprising 20 systematic reviews, 10
meta-analyses, and two pooled analyses. Review funding
sources and conicts of interests are presented in Supple-
mental Table 4.
Aim 1: breadth and scope of reviews
An overview of the population and behaviors included is
provided in Table2. e 32 reviews included a median
of 26 studies (range: 5-141 studies) and compared
4,785,140 participants in total. All ages were represented
in this umbrella review, with some reviews including
all ages (5/32), or only children and adolescents (ages
3-17 [51−53] or 5–17 years) [19, 54–59]. Other age
groups explored across the lifespan were young chil-
dren (0–5 years) [29, 31, 60], college/university students
(ages ∼ 18–25 years) [61], and older adults (mean age ≥ 60
years) [62, 63]. Populations were also dened by nation-
ality, location, and occupation, including: immigrant
children [54], children and adolescents from Arabic
countries [64], and airline pilots [65]. Population de-
nitions were rarely conned to health or disease status,
such as only including healthy populations [32, 60, 62,
66], or individuals with type 1 diabetes [55]. Beyond pop-
ulation characteristics, the time frame was another con-
sideration as four reviews were specic to the COVID-19
pandemic [19, 20, 67, 68], while one review specically
excluded COVID-19 studies [51]. Finally, all reviews
assessed physical activity, and most reviews assessed all
three behaviors (physical activity, sedentary behavior or
screen-time, and sleep, 26/32). irty reviews assessed
sedentary behavior, of which three specically did not
assess screen-time [33, 65, 66], nine reviews explicitly
allowed screen-time as either a sedentary behavior indi-
cator or separate behavior [19, 21, 51, 52, 55, 56, 59, 60,
69], and the remaining 18 reviews did not clearly state
if screen-time would be considered in their review (See
Supplemental Table 5).
As for review conduct, most reviews were regis-
tered and noted all study designs were eligible (≥ 20/32,
Table 2). e median number of scientic databases
searched was 4 (range: 3–14), which were searched from
inception and six reviews searched since the guide-
lines were created in 2015 or 2016. All reviews searched
MEDLINE or Pubmed, followed closely by six data-
bases: Embase (21/32), PsychINFO (20/32), SportDiscuss
Page 6 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
(18/32), Scopus (16/32), CINAHL (12/32) or Web of Sci-
ence (11/32). Less than ten reviews searched Cochrane
Libraries (4/32), specic gray literature sources (e.g., Pro-
Quest, 1/32), or other search engines. Reviews obtained
a median of 26 studies (range: 5-141), including stud-
ies conducted in predominately high-income western
countries (e.g., Australia, Canada, United States), east or
southeast Asia (e.g., China, Malaysia, ailand), or Latin
America and the Caribbean (e.g., Bahamas, Brazil, Chile,
), though four reviews did not report the country where
their retrieved studies occurred (Table2) [24, 52, 62, 66].
Most reviews were published in 2023 (12/32), or between
2020 and 2022 (14/32). Details of included reviews in can
be found in Supplemental Table 5.
Methodological quality
irty reviews were given overall ratings based on criti-
cal and non-critical domains, as the two pooled analyses
were not given an overall rating. One systematic review
[23] and one meta-analysis [51] were rated as “moderate”
quality, indicating no critical weaknesses and few non-
critical weaknesses. In contrast, due to the high number
of critical weaknesses, seven reviews were rated as “low”
[4, 31, 57, 59, 63, 68, 70], and the remaining 21 reviews
were rated as “critically low” quality. Beginning with
critical domains, most reviews achieved the partial or
full standard for review methods (22/30 reviews), search
strategy (30/32 reviews), risk of bias tool (26/32 reviews),
or statistical methods (10/12 meta-analyses), but few
provided a list of excluded studies with reasons (5/32
reviews) or assessed publication bias (4/12 meta-anal-
yses). As for non-critical domains, about half of reviews
met standards for delineating participant, intervention/
exposure, comparator, and outcome, describing included
studies, study selection, and reporting authors conict of
interest (≥ 19/32 reviews for each). Few reviews met the
non-critical domains of clarifying study designs included
(6/32 reviews), reporting funding for included studies
(0/32 reviews), and risk of bias assessment in analysis
(2/12 meta-analyses). Critical and non-critical domain
scores for individual reviews are displayed in Supplemen-
tal Table 6.
Aim 2: prevalence of meeting 24-hour movement
guidelines
Prevalence estimates were focused primarily on children
and youth or during the pandemic, and only two reviews
reported estimates for adults. As shown in Supplemental
Table 7, estimates from the seven reviews that reported
prevalence estimates for children and youth were derived
from a median of 17 studies (range: 1–63 studies). Most
child prevalence estimates were calculated based on the
Fig. 1 PRISMA 2020 ow diagram for new systematic reviews which included searches of databases, registers and other sources From: Page MJ, McKen-
zie JE, Bossuyt PM, Boutron I, Homann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ
2021;372:n71. doi: https://doi.org/10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/
Page 7 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
Canadian 24-hour movement guidelines (5/6), [21, 51,
56, 60, 68] with only one review using another guide-
line denition (i.e., > 20min of vigorous intensity physi-
cal activity or > 30min of moderate physical activity, > 3
days/week)[54] In general, reviews found around half
of children met the physical activity guideline (estimate
range: 22.3–67%), less than a third met the screen-time
guideline (estimate range: 10-28.3%), and half or more
met the sleep guideline (estimate range: 57-83.5%, Sup-
plemental Table 7 and Fig. 2). Some children (estimate
range: 7-28.6%) met 0 guidelines, a third each met 1 or 2
guidelines (estimate range: 27.7–50.6%), and few met al.l
the guidelines (estimate range: 3.5–12.8, Supplemental
Table 7and Fig. 2). Individual and total guideline adher-
ence waned from preschool to adolescence. Two reviews
that assessed behaviors during the COVID-19 pandemic
documented slightly lower prevalence estimates for phys-
ical activity [68], sleep [68], and meeting all three guide-
lines [20]. ese similarities are not without caution; the
three meta-analyses pooled estimates revealed high het-
erogeneity amongst their individual studies (i2 > 95)[51,
60, 68]. In addition to children, one systematic review
and one pooled analysis assessed prevalence of 24-hour
movement behaviors in adults, including in airline pilots
and UK adults before and during the COVID-19 pan-
demic [65, 67]. ese reviews used dierent metrics
for insucient activity (i.e., not meeting physical activ-
ity guidelines), which resulted in ranges of 51.3–51.7%
for airline pilots (< 150 min/week of MVPA, 5 studies,
2233 participants), [65] and 21.2–49.9% for adults pre-
COVID-19 and 20-42.3% for adults during the COVID-
19 pandemic (≤ 3days of at least 30min/day of exercise,
6 studies, 19,331 participants) [67]. Similar sleep guide-
lines were used for insucient sleep, which found 22%
prevalence in airline pilots (< 6h/night, 3 studies, sample
size not reported) [65] and various ranges for adults pre-
COVID-19 (< 6h or 9 + hours/night, range: 6.8–14.5%, 6
studies, 19,331 participants) and during the COVID-19
pandemic (12.2–29.9%) [67].
Aim 3: associations between 24-hour movement behaviors
with health outcomes
Twenty-six studies were included in this Aim. An over-
view of review characteristics is presented in Table 3,
and review details are documented in Supplemental
Tables 8 and 9. ese reviews predominantly approached
24-hour movement behaviors using ISM or CoDA tech-
niques, evaluating 24-hour movement behavior’s inter-
active associations with health outcomes, guideline
adherence, and created prole-based groups based on
level of engagement in 24-hour movement behaviors
(e.g., high PA and low SB groups). Only three of the ISM
reviews specically focused on studies using the compo-
sitional ISM approach [4, 29, 30], and the ve other ISM
reviews included both compositional and traditional
ISM approaches [23, 24, 58, 66, 70]. Reviews primarily
assessed physical health outcomes (22/26). Overwhelm-
ingly (≥ 11/26), many reviews assessed weight, cardio-
metabolic health markers, and tness, and six reviews
also included mortality [4, 23, 30, 32, 33, 70]. Reviews
included a median of 26 studies (range: 5-141 studies),
including a median of 21 cross-sectional (range: 0-119),
Table 2 Characteristics of included reviews related to 24-hour
movement behaviors (n = 32)
Characteristic n%
Life Stage Included#
0-2y 12 38%
3-4y 15 47%
5–12 y 19 59%
13-17y 20 63%
18-25y 12 38%
26-55y 11 34%
55 + y 13 41%
All ages 5 16%
24-hour Movement Behaviors#
Physical Activity 32 100%
Sedentary Behavior 30 94%
Sleep 28 88%
All three behaviors 26 81%
Screen-time^ 9 28%
Review Registration
PROSPERO 21 66%
Open Science Framework 4 13%
Not Registered 7 22%
Study Design Eligible#
All study designs 20 63%
Observational studies 8 25%
Prospective Design 1 3%
Not described 3 9%
Search Dates
Inception 23 72%
Guidelines Creation (2015 or 2016) 6 19%
COVID-19 date (2020 or 2021) 2 6%
Other 1 3%
Regions Represented in included studies#
Central Asia, Middle East, North Africa 9 28%
Central and Eastern Europe 11 34%
East and Southeast Asia 17 53%
High-income Asia Pacic 15 46%
High-income western 26 81%
Latin America and Caribbean 16 50%
Oceania 1 3%
South Asia 10 31%
Sub-Saharan Africa 11 34%
Multination studies 4 13%
Country/region not described 5 16%
Review did not present region information 4 13%
^Specied screen-time as part of inclusion criteria; #Reviews may include
multiple ca tegories, hence the tot al amount will not add up to 100%
Page 8 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
and 5 longitudinal studies (range:0–25). ree reviews
found no longitudinal studies [32, 56, 61, 62], and eight
reviews included other study designs [19, 30, 31, 53, 55,
61, 64, 69], like results of an MVPA intervention on feel-
ings of energy [61]. Reviews assessed study quality and
risk of bias of included articles through diering tools
with or without modications (e.g., Down’s and Black,
Cochrane Library Risk of Bias tool, modied checklist
based on reporting standards), resulting in diverse dis-
tributions of high- and low-quality articles. Notably, all
Fig. 2 Review-calculated proportion meeting respective guidelines. Panel A: Number of Guidelines; Panel B: Specic Guidelines Panel A: ^ denotes es-
timates that were recalculated to proportion met as they were reported as proportion who did not meet the guidelines; gray circle = 0 guidelines; black
circle = 1 guideline; black square = 2 guidelines; gray square = 3 guidelines; Panel B: *Ahmed, 2021 physical activity guidelines used was " >20min of Vigor-
ous intensity physical activity or > 30min of moderate physical activity, > 3 days/week”, sleep guideline was not clearly dened; ∼ denotes studies during
SARS COVID-19 pandemic status; black triangle = physical activity guideline; gray triangle = screen-time guideline; black diamond = sleep guideline
Page 9 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
six reviews that used the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) tool
to assess level of evidence found “low” or “very low” qual-
ity of evidence for their health outcome, mainly due to
serious risk of bias and inconsistency [4, 31, 56, 57, 63].
Physical activity, sedentary behavior, and sleep were
clearly dened in less than a third of the reviews (see
Supplemental Table 8). For physical activity, ve reviews
utilized the Caspersen denition of physical activity
movement (“any bodily movement produced by skeletal
muscles that results in caloric expenditure”) [35] or met-
abolic equivalent of task (MET) intensity (> 3.0 METs)
[4, 29, 57, 63, 64], and two reviews dened it as seden-
tary screen-time [56]. Similarly, sedentary behavior was
dened by wake-time MET intensity (< 1.5 MET) and sit-
ting, standing, or reclining state as well [4, 29, 56, 64], and
two reviews dened it as sedentary screen-time [56] or
non-screen and screen-based sedentary behaviors [55].
Sleep was dened broadly, including altered conscious-
ness, inhibition of muscles and reduced interactions; [64]
and MET intensity (∼ 1) [63]. One review dened physi-
cal activity or sedentary behavior by any activity, time,
or type; [32] another review dened each behavior based
on the Canadian Society for Exercise Physiology 24-hour
movement guidelines [71]. Other reviews indirectly
dened these behaviors by solely including device-based
measures for physical activity and sedentary behavior
[66, 70], or only physical activity [23, 53]. One third of
reviews did not dene measurements (e.g., device-based
only, device and questionnaire) as part of their inclusion
criteria for physical activity (6/27), sedentary behav-
ior (9/27), or sleep (9/27). Two reviews [66, 70] and the
pooled analyses [33] were conned to only device-based
measures, as all others considered device, question-
naire, or other measures for 24-hour movement behavior
assessment (Supplementary Table 8). ese heterogenous
terminologies and methods precluded detailed inves-
tigation into how these various components may have
inuenced reviews ndings, but overall results were qual-
itatively compared.
Interactive behavior examinations were common.
Higher amounts of MVPA were favorable for child
weight-related outcomes [64], child tness [53], young
child motor skills [60], and mortality [33]. is evidence
was replicated in ISM reviews, where reallocating sed-
entary time to MVPA was related to favorable changes
in weight [23, 24, 58], cardiometabolic health [58, 66,
70], tness [4, 23], and mortality [4, 23, 33, 70]. ese
results were not always replicated when replacing sed-
entary time for light physical activity for weight-related
outcomes [4, 24, 58] or tness [58], but one review found
evidence for waist circumference and fasting insulin [70].
Favorable results for increased amounts of MVPA on
child depression [64], adult quality of life [55, 63], and
other child mental health indicators were also found [71].
Accordingly, one ISM review found reallocating seden-
tary time to MVPA was related to favorable adult men-
tal health [23]. e remaining behaviors of sedentary
time and sleep had fewer comparisons, and results were
mixed based on outcomes. Unfavorable results from high
amounts of sedentary time were found for child tness;
[53, 64] while others found null or mixed results for adult
cardiometabolic health markers [55, 66]. Chastin et al.’s
pooled analysis found associations between the ratio of
light physical activity and sedentary time to mortality in
hip-measured accelerometer studies, but not wrist-mea-
sured studies [33]. One ISM review reported unfavorable
results for hypothetically substituting MVPA to seden-
tary time on weight and mortality [4]. Better sleep, either
sleep quality or duration, was associated with favorable
results for depression and anxiety in individuals with
type 1 diabetes [55] and adult fatigue/energy [61]. Mixed
(i.e., some favorable, some null) or overall null associa-
tions were found between better sleep and young child
[60] and child weight [64], and HbA1c in individuals with
type 1 diabetes [55]. Substituting time in sleep to other
behaviors had a null eect on weight [4, 30], cardiometa-
bolic health markers [30], tness [53], and mortality [4,
33].
Behaviors were also classied by adherence to the
24-hour movement guidelines or amongst prole-based
Table 3 Characteristics of included reviews related to 24-hour
movement behaviors and health outcomes (n = 26)
Characteristic n%
Assessment of 24-hour movement behaviors
Isotemporal Substitution Modelling 8 30%
Individual Behaviors 7 27%
Guideline Adherence 6 23%
Prole-Base Analysis 4 15%
Pooled Analysis 1 3%
Physical Health Outcomes Assessed#22 84%
Weight-related 16 61%
Cardiometabolic Health Markers 11 42%
Fitness 11 42%
Mortality 6 23%
Motor Skills 4 15%
Other 7 27%
Mental Health Outcome Assessed#14 53%
Depression or Anxiety 6 23%
Mental Wellness 4 15%
Quality of Life 4 15%
Cognition/cognitive development 3 12%
Behavioral Problems 2 7%
Other 6 23%
#Reviews may include multiple c ategories, hence the tot al amount will not add
up to 100%; Othe r physical health outcom es included bone heal th, and chronic
diseases; Other mental health outcomes included coping, energy or fatigue,
mental health, psychosocial health, and perceived/general health status,
Page 10 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
groups. Meeting all three guidelines was associated with
favorable child weight-related outcomes [21, 52, 69], but
these results did not translate consistently to toddlers [60]
and preschoolers [60, 69]. Meeting all three guidelines
was associated with favorable associations for young chil-
dren’s motor skills [60], children’s cardiometabolic health
markers, tness, cognition, and mental health [21], and
adolescent depression [56]. Few reviews evaluated meet-
ing one or two guidelines, or dose response associations
of meeting an increasing number of guidelines on health
outcomes. Kuzik et al. found favorable results with meet-
ing two guidelines of various iterations on young child
weight, tness and motor skills [31], but Feng et al. found
an overall null eect for young child weight for those who
met two guidelines [60]. Feng et al. also reported a mixed
association between meeting more guidelines and young
child weight, and null associations of meeting the screen-
time guideline and young child weight [60]. Reviews that
focused on classications of physical activity, sedentary
behavior, and sleep or 24-hour movement composition
found similar results [29]. Children with high amounts of
physical activity, low amounts of sedentary behavior, and
longer sleep had favorable weight-related [57] and mental
health outcomes [59]. Mellow et al. found only two stud-
ies that explored all three behaviors with older adult cog-
nition, though their results generally support adequate
amounts of all three behaviors [62]. Duncan et al. fur-
ther explored the eect of physical activity and sleep on
mortality to nd that high levels of physical activity may
reduce mortality risk in the presence of short sleep [32].
Discussion
is review’s purpose was to characterize the breadth
and scope of current 24-hour movement behavior
reviews, examine prevalence estimates for 24-hour
movement guideline adherence, and examine the asso-
ciation between these behaviors and health outcomes by
diering approaches. e current landscape of systematic
reviews has spanned all ages, global regions, and study
designs, but in contrasting amounts and low or criti-
cally low systematic review quality. Diering approaches
to 24-hour movement behavior research provide an
opportunity to answer unique questions regarding the
collective inuence of these behaviors on health, fur-
ther deepening our understanding of the implications of
behavioral time-use across the course of a 24-hour day.
High amounts of MVPA, reallocating sedentary behav-
ior to MVPA, and meeting all three 24-hour movement
guidelines demonstrated clear health benet, with less
certainty for sedentary behavior and sleep. is review
demonstrates that systematic reviews, and hence our
understanding, of the inuence of 24-hour movement
behaviors on health is in its nascency, with opportunities
to increase future review’s representation, rigor, and
reporting.
e breadth and scope of current 24-hour movement
behavior research is wide across ages, regions, and time
frames (i.e., pre-COVID-19 and COVID-19), prov-
ing to be both a positive and negative quality. On the
one hand, multiple ages, regions, and time periods were
represented; on the other hand, this vast scope was not
consistent across reviews (i.e., some only captured pre-
dominately high-income countries in a narrow age range)
[29] and was conducted with varying rigor. Global repre-
sentation is a key issue within behavioral research [72],
as ndings from predominately high-income western
country may not translate to other geographical regions.
A review focusing specically on children from Arab-
Speaking countries exemplied this consideration by
solely investigating a specic region (i.e., Central Asia,
Middle East, and North Africa) [64]. Few other reviews
studied subpopulations as most reviews aligned with
the early guidelines for children and adolescents [8,
9], and no reviews focused on the recent adult or older
adult guidelines [14]. One review attempted to examine
older adult literature but found few articles with all three
behaviors [62]. is disparity is likely due to few papers
using these standards, or current studies still using past
individual guideline stipulations [73, 74], as demon-
strated in the retrieved adult prevalence reviews [65, 67].
Guideline adherence and overall investigation during the
COVID-19 pandemic was minor [19, 20, 67, 68], but this
time period may continue to be a consideration as fur-
ther systematic reviews are conducted from database
inception.
Despite the many approaches used, these 24-hour
movement behavior reviews consistently found high
amounts of MVPA and meeting all three guidelines
were benecial for various indicators of health. e cur-
rent yield of systematic reviews also found more reviews
investigated physical health outcomes relative to men-
tal health outcomes. e most explored outcome was
weight, which may be due to the relative ease of obtain-
ing this measure, and continuing increase in childhood
obesity prevalence over the past decades [75]. Poor men-
tal health, especially in youth, is another public health
concern which was brought to the forefront amongst
changes in all three behaviors during the COVID-19
pandemic [19, 76]. Even so, reviews focused on mental
health were less represented in this population, but are
deserving of more attention. Since this current umbrella
review’s search, another systematic review examined
24-hour movement behavior’s association with indica-
tors of mental health and wellbeing has been published;
[6] this new publication and others is promising for men-
tal health receiving additional attention. Future reviews
into less represented outcomes, such as bone health,
Page 11 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
functional measurements, stress, and coping may help
expand our understanding of the entire 24-hour day for
tailored interventions.
Consistent prevalence estimates and ranges (i.e., within
10%) were represented in adherence to individual and
total guidelines across childhood. Notably, these multi-
behavior results align with the original guidelines created
based on single behavior investigations [1–3, 5]. Consis-
tent support for high MVPA with improved health out-
comes also aligns with existing evidence-based guidelines
[18, 73], and general agreement for all reviews assess-
ing the aerobic component of the guidelines (MVPA)
rather than muscle-strengthening. ese consistent stan-
dards and results did not translate to sedentary behav-
ior or sleep. Excess wake time spent sedentary (MET
value ≤ 1.5) is associated with poor health outcomes [77,
78], with pronounced impacts amongst those achiev-
ing lower amounts of MVPA [79], when considered as
TV [80] or sedentary screen-viewing time [81], or using
hip-mounted device-based measures compared to wrist-
worn devices [33]. ese intricacies were rarely addressed
or dened in the current reviews, as exemplied by few
reviews providing exact denitions for sedentary behav-
ior, including wakeful state, MET value, and posture, or
their inclusion of screen-time. ese ndings are disap-
pointing as there have been agreed upon terminology for
sedentary behavior and related states for almost a decade;
moreover, these terms are a key consideration of exist-
ing frameworks and guidelines [15, 36]. ese behavior
nuances also translate to sleep, which may be considered
based on duration, quality, timing, and many other met-
rics [77]. e metrics may not be considered amongst
most approaches which solely focus on duration-based
time-use estimates, whereas approaches using other
groupings may consider the negative synergistic eects
and other context considerations of low physical activity
and poor sleep on health [31, 32, 82].
e critically low quality of reviews must be acknowl-
edged in our consideration of movement behaviors in
relation to physical and mental health outcomes. ough
many areas could be improved, it is important to consider
these two main areas: (1) not clearly describing eligible
study designs and (2) assessing various sources of bias.
Reviews predominately included all study designs, which
may prevent utilizing this practice. is wide inclusion
criteria may be able to capture a larger yield of articles
in a growing landscape; this wide inclusion criteria may
also be problematic in terms of introducing heteroge-
neity. Reviews conducted prior to 2020 likely had fewer
studies available [21], but recent reviews did not improve
this practice. e second area of consideration was evalu-
ating and assessing publication and risk of bias amongst
these retrieved studies. Without assessing these areas,
it is unclear if meta-analytic results can be attributed to
balanced, high-quality studies.
Strengths of the current review include the inclusion of
a novel eld of inquiry, rigorous review strategy by fol-
lowing review best practices [49], and timely evaluation
as we approach a decade with the 24-hour movement
guidelines. is review is not without limitations, namely
conned to review conduct and topic matter consider-
ations. e review conduct considerations include search
date, English language stipulations, and included all three
behaviors, which may impact inclusion of recent (pub-
lished in 2024) [6, 83], non-English language reviews, and
dual behavior studies. ese limitations were addressed
through a comprehensive search strategy of international
experts and a leading international database (Interna-
tional Network of Time-Use Epidemiologists) to ensure
all reviews that met these standards were included. e
topic matter considerations are diverse approaches of
included reviews, and restricted clinical utility of a hypo-
thetical substitution approach. ese considerations
hinder major statements on the association between
24-hour movement behaviors and health outcomes but
improve our understanding of 24-hour movement behav-
iors in diering ways (e.g., optimal amount, trends, and
prevalence) [15]. Moreover, individual behavior focused
reviews were not included in this review [84, 85], which
may curb our prevalence estimates and understanding of
individual behaviors. is review contributes to evidence
of the current breadth and scope of reviews that included
multiple 24-hour movement behaviors, and the relation-
ship with these multiple behaviors and health outcomes.
Results of this review posit four major improvements
in future research conduct and study design. First, multi-
behavior longitudinal studies are warranted to enhance
the quality of existing evidence. ese secondary data
analyses and future studies will only be helpful if agreed
upon terms and reporting of 24-hour movement behav-
iors is achieved, which can in turn advance existing
frameworks in this area [15]. erefore, the second area
is potential creation of reporting practices for 24-hour
movement behaviors approaches, such as CoDA, guide-
lines adherence, and interactive associations, through
an iterative process with experts and end-users. Beyond
the number of guidelines achieved or correctly clas-
sifying approaches (i.e., individual behaviors evaluated
collectively, guidelines), an activity [86] or movement
index [87] allows characterizing of multiple behaviors
and investigation in eventual 24-hour interventions [88].
Alignment of terminology also should be accompanied
by assessment method, as there are challenge and oppor-
tunities to self-report and device-based methods for
quantifying 24-hour movement behavior. Dissemination
and wide-spread adoption of such approaches and pos-
sible reporting checklists is paramount, as evidenced by
Page 12 of 15Kracht et al. Journal of Activity, Sedentary and Sleep Behaviors (2024) 3:25
few reviews using existing guidance for sedentary behav-
ior terminology [36]. e third area of improvement is
conducting systematic reviews evaluating the preva-
lence and benet of 24-hour behaviors amongst special
populations not currently represented in the literature,
including individuals with physical and developmental
disabilities [89, 90], and pregnant or postpartum individ-
uals [91, 92], as they report even lower adherence to all
three guidelines. ese eorts should also support review
approaches to improve inclusion globally and research
initiatives to expand to lesser represented regions [93].
Finally, future reviews should consider consulting exist-
ing standards for high quality systematic reviews and
meta-analyses [49] to vastly improve the current scenery
of poor-quality reviews.
is umbrella review revealed that the breadth and
scope of existing literature on 24-hour movement behav-
iors is wide; this literature spans all ages and regions in
dierent capacities. Included reviews permitted many
denitions and approaches to analyzing associations
between 24-hour movement behaviors and health out-
comes and were overall low quality; both qualities hin-
dered harmonized synthesis. Amongst these weaknesses,
a consistent nding was improved health benet from
additional MVPA and meeting all three guidelines, with
inconsistent ndings for sedentary behavior and sleep.
Given the collective and individual benet of these
behaviors, the next decade should focus on harmonized
rigorous research using a multi-behavior approach to
improve existing evidence.
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s44167-024-00064-6.
Supplementary Material 1
Acknowledgements
We gratefully acknowledge the experts who responded with their insights on
extraction items and for additional articles (Dr. Matthew Buman, Dr. Catherine
Draper, Dr. Benny Kai Gui Loo, Dr. Anthony Okely, Dr. Richard Rosenkranz, Dr.
Emmanual Stamatakis, Dr. Marie-Pierre St-Onge, Dr. Rachael Taylor, Dr. Mark
Tremblay, Dr. Corneel Vandelanotte). We would also like to acknowledge Matt
Hayward of University Health Sciences of Texas San Antonio, the research
librarian, for their contributions to the search strategy and search conduct.
Author contributions
CLK contributed to conception, overall design, implementation, data
screening and extraction, data analysis, and writing the initial draft. SB, CIG,
GMB, CDPf, and CWSL contributed to design, data screening and extraction.
CDPo prepared tables. DB contribution to conception, overall design, and
data screening and extraction. EKJ contributed to the study search strategy
and search process. All authors critically commented and revised text, and
approved the submission of the nal version.
Funding
(1) CLK was supported by K99HD107158 (PI: Kracht), R00HD107158 (PI: Kracht),
and P20GM144269 (PI: Kracht), and SB was supported by P20GM130420 (PI:
Burkart). The content is solely the responsibility of the authors and does not
necessarily represent the ocial views of the National Institutes of Health.
The funders had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review,
or approval of the manuscript; and decision to submit the manuscript for
publication. (2) GMB is jointly funded by the Canadian Institutes of Health
Research and Michael Smith Health Research BC postdoctoral fellowships.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City,
KS 66160, USA
2Arnold School of Public Health, University of South Carolina, 921
Assembly St, Columbia, SC 29208, USA
3The University of Texas at San Antonio, 1 UTSA Circle, San Antonio,
TX 78249, USA
4The University of British Columbia, 2215 Wesbrook Mall, Vancouver,
BC V6T 1Z3, Canada
5School of Public Health in Austin, The University of Texas Health Science
Center Houston, Austin, TX 78701, USA
6The University of Massachusetts Amherst, Amherst, MA 01003, USA
7Department of Kinesiology, Kansas State University, 1105 Sunset Ave,
Manhattan, Kansas 66502, USA
Received: 8 July 2024 / Accepted: 19 September 2024
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